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OPINION OF TRUSTEES
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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 84-496 – September 14, 1988

Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee.

Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for treatment of temporomandibular joint dysfunction under the terms of the Employer Benefit Plan.

Background Facts

The Employee’s spouse has temporomandibular joint dysfunction (TMJ) manifested by severe headaches, popping and locking of the jaws and pain in her ears, jaws, neck and shoulders. The Employee’s spouse was referred to an oral surgeon who fitted her with a removable maxillary orthopedic appliance to correct the discrepancy between the condyle of the mandible and the temporal bone. The treatment plan involved use of this device for eight to ten weeks followed by re-evaluation of her condition and determination of a plan for permanent stabilization of the joint.

The Employer denied payment for the appliance because the Employee failed to obtain prior approval from the Plan Administrator for treatment fur TMJ syndrome.

Dispute

Is the Employer responsible for the provision of health benefits coverage for the treatment of the Employee’s spouse’s TMJ dysfunction?

Positions of the Parties

Position of the Employee: The Employer is responsible for the provision of health benefits coverage for the treatment of the Employee’s spouse’s TMJ dysfunction.

Position of the Employer: The Employer is not responsible for the provision of health benefits coverage for the treatment of the Employee’s spouse’s TMJ dysfunction because she did not obtain prior approval from the Plan Administrator for such treatment.

Pertinent Provisions

The Introduction to Article III of the Employer Benefit Plan states in part:

Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan.

Article III. A. (3)(e) of the Employer Benefit Plan states:

(e) Oral Surgery

Benefits are not provided for dental services. However, benefits are provided for the following limited oral surgical procedures if performed by a dental surgeon or general surgeon:

Tumors of the jaw (maxilla and mandible)
Fractures of the jaw, including reduction and wiring
Fractures of the facial bones
Frenulectomy when related only to ankyloglossia (tongue tie)
Temporomandibular joint dysfunction, only when medically necessary and related to an oral orthopedic problem
Biopsy of the oral cavity
Dental services required as the direct result of an accident

Article III. A. (3)(m) of the Employer Benefit Plan states:

(m) Specialist Care

Benefits will be provided for treatment prescribed or administered by a specialist if the treatment is for illness or injury which falls within the specialist’s area of medical competence.

Q&A 81-88 states:

Subject: Oral Orthopedics
References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (3) (e) and (m), and A (11) (a) 19

Question:

Are benefits provided for treatment of Temporomandibular joint Dysfunction?

Answer:

No, except when treatment involves:

1. the use of corrective external orthopedic appliances; or

2. corrective surgery to specifically reorient the temporomandibular joint.

If either treatment is to be rendered by an oral surgeon, prior approval must be obtained from the Plan Administrator.

Benefits are not provided for treatment for T.M.J. which involves the insertion of dentures.

Discussion

The Introduction to Article III of the Employer Benefit Plan states that covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care. Article III. A. (3)(e) of the Employer Benefit Plan provides that oral surgical treatment for TMJ dysfunction is a covered benefit only when it is medically necessary and related to an oral orthopedic problem. Under Article III. A. (3)(m) of the Plan, benefits are provided for treatment prescribed or administered by a specialist if the treatment is for illness or injury which falls within the specialist’s area of medical competence.

In this case, the Employee’s spouse’s general dentist referred her to an oral surgeon for the evaluation and treatment of her TMJ dysfunction. Upon completion of his evaluation, he referred her to an oral surgeon whose practice is limited to the treatment of TMJ disorders and craniofacial pain and who prescribed a corrective external orthopedic appliance for her to wear.

A Funds’ medical consultant has advised that in his opinion the Employee’s spouse does have TMJ dysfunction and the prescribed treatment of wearing a corrective external orthopedic appliance is medically necessary for treatment of her illness. In this case, the TMJ treatment is not a dental service (i.e. braces, surgery to correct the bite, etc.); rather it is a medically necessary orthopedic service which specifically reorients the temporomandibular joint. Consequently, coverage is considered on the same basis as treatment for other bones and joints of the body. Although the treatment provided here is not an oral surgical procedure, the use of a corrective external orthopedic appliance is a more conservative means of treating TMJ dysfunction. It is consistent with the appropriate level of care requirement under the Plan to provide benefits under Article III. A. (3)(e) for the use of a corrective external orthopedic appliance in cases where the TMJ dysfunction may be corrected non-surgically. Because the Employee’s spouse was treated by a specialist for an illness (TMJ dysfunction) which fell within his area of medical competence and such treatment was medically necessary and related to an oral orthopedic problem, consistent with Article III. A. (3)(e) of the Plan, the specialist’s services are covered, as is the charge for the medically necessary orthopedic appliance he prescribed.

The Trustees note that the Employer Benefit Plan itself contains no requirement that prior approval be obtained for TMJ treatment. Furthermore, there is no evidence indicating that the Employer notified its participants of such a requirement. The Trustees are therefore of the opinion that the Employee was not required to obtain prior approval in this situation.

Opinion of the Trustees

The Employer is responsible for the provision of health benefits coverage for the treatment of the Employee’s spouse’s TMJ dysfunction.